Original Article

Ling ZJ, Lian WB, Ho SKY, Yeo CL
Correspondence: Dr Lian Wee Bin, lian.wee.bin@sgh.com.sg

ABSTRACT
Introduction Current medical advances have increased the survival rate of the premature infant with its complications. Risk factors for prematurity include maternal diabetes mellitus, hypertension, smoking and alcohol intake.
Methods A true/false questionnaire survey focusing on risk factors, outcomes/follow-up and costs was administered to adults attending a parenting-related public forum. One point was awarded per correct answer. Entire prematurity knowledge and section T-scores were calculated, (a pass mark was defined as at least 50 percent for each T-score). Missing answers and affected T-scores were considered invalid.
Results There were 81 respondents: predominantly within 21–40 years of age, Chinese, female, public-housing dwellers, first-time parents-to-be and with graduate or higher-level qualifications. A pass in entire and prematurity knowledge T-scores was achieved in 69 percent (median 13 [range 3–21]) and 62 percent (median 12 [range 0–19]) respectively. A pass in section T-scores on risk factors, outcomes and costs was achieved in 62, 53 and 75 percent, respectively. Awareness of risks and outcomes did not correlate with awareness of costs. Logistic regression did not reveal any factors contributing to a pass or higher T-scores.
Conclusion Although the majority achieved a pass in all T-scores, general knowledge among this childbearing group was deemed inadequate by the median scores. As survival improves, awareness of prematurity and its risks has to be improved, with a target to reduce the incidence of prematurity and to support those infants who require resource-intensive follow-up.

Keywords: antenatal care, infants, neonatal risk factors, parental knowledge, preterm labour
Singapore Med J 2009; 50(3): 270-277

Suzana S, Cham BG, Ahmad Rohi G, Mohd Rizal R, Fairulnizal MN, Normah H, Fatimah A
Correspondence: Dr Suzana Shahar, suzanas@medic.ukm.my

ABSTRACT
Introduction The purpose of this study was to assess the relationship between selenium status and intake among breast cancer patients from the Klang Valley.
Methods 64 cases and 127 controls were matched for age (range 30–65 years) and ethnicity, with an 80 percent study power. Subjects were interviewed to obtain information on their habitual dietary intakes, demographic data and medical history. Selenium status was determined from toenail and hair analysis using an inductively coupled plasma mass spectrometer.
Results The nutrient analysis showed that total energy and protein intake was significantly higher among controls (1,403 +/- 367 kcal/day, 75.6 +/- 33.2 g/day) as compared to cases (1,273 +/- 295 kcal/day, 60.9 +/- 19.1 g/day) (p-value is less than 0.05). The selenium intake among cases (78.47 +/- 25.34 µg/day) was significantly lower than the controls (89.34 +/- 36.85 µg/day) (p-value is less than 0.05). Breast cancer risk decreased with the increasing quartiles of selenium intake, with odds ratios (95 percent confidence interval) of 2.95 (1.22–7.12), 2.17 (1.13–4.19) and 1.71 (0.84–3.52), respectively. However, the association diminished after adjustment for confounding factors. Selenium in hair did not differ among cases and controls, but selenium status in the nails of controls was significantly higher as compared to cases (p-value is less than 0.05). Breast cancer risk decreased with the increasing quartiles of toenail selenium status as measured in the toenail and hair.
Conclusion Selenium intake and status was associated with breast cancer risk. Thus, it is essential for Malaysian women to achieve a good selenium status by consuming good food sources of selenium as a chemopreventive agent.

Keywords: selenium, breast cancer, cancer risk factors, case-control studies, chemopreventive agent, selenium intake
Singapore Med J 2009; 50(3): 265-269

Tang IP, Shashinder S, Gopala Krishnan G, Narayanan P
Correspondence: Dr Ing Ping Tang, ingptang@yahoo.com

ABSTRACT
Introduction This is a retrospective study that aimed to examine the outcomes of patients presenting with juvenile nasopharyngeal angiofibroma (JNA) at a tertiary centre in Malaysia.
Methods The demographical data, clinical presentation, investigations as well as treatment of 13 JNA patients were reviewed and collected from the medical record office at our centre from 1995 to 2005.
Results All JNA patients were male and the average age at diagnosis was 17 (range 14–28) years. They presented with recurrent painless spontaneous epistaxis, nasal obstruction, nasal discharge, a reduced sense of smell, snoring, headache and facial swelling. One patient was at stage I, eight were at stage II, three at stage III and one patient was at stage IV, based on the Fisch classification. Angiography showed that nine tumours were supplied by both internal maxillary arteries of the external carotid system, and only four tumours received blood supply from the ipsilateral internal maxillary artery. All 13 patients underwent primary surgical resection. The overall recurrence rate was 38.5 percent for the first procedure and 60 percent for the second procedure. No major complications occurred in this group of patients as a consequence of treatment, neither for the primary tumours nor for the recurrences.
Conclusion JNA is a rare vascular benign tumour with highly exclusive persistence and recurrence, and typically affects adolescent boys. The management of JNA presents a challenge to ENT surgeons. Preoperative angiography and embolisation minimise intraoperative blood loss and the current shift in the treatment to endoscopic excision in selected lesions reduces perioperative morbidity.

Keywords: angiofibroma, juvenile nasopharyngeal angiofibroma, nasopharyngeal tumour
Singapore Med J 2009; 50(3): 261-264

Tan HH, Lee GH, Thia KTJ, Ng HS, Chow WC, Lui HF
Correspondence: Dr Hui-Hui Tan, tan.hui.hui@sgh.com.sg

ABSTRACT
Introduction Minimal hepatic encephalopathy (mHE) has been reported in up to 84 percent of cirrhotics. The natural history of mHE has not been well-described. We designed a three-year prospective cohort study to determine the prevalence and natural history of mHE among cirrhotic patients.
Methods The patient cohort comprising 62 consecutive outpatients with cirrhosis were assessed at baseline and followed-up with a repeat assessment three years later. The assessments include: (1) Neuropsychometric analysis (digit-symbol substitution test, block-design test, number-connection test A); (2) Clinical, biochemical assessment; and (3) Quality of life (QOL) assessment (abbreviated sickness impact profile).
Results Baseline characteristics were: age 52.9 +/- 11.0 years; Child’s A:B:C was 46:14:2. mHE was detected in 33.9 percent of the cohort. Older age, a higher Child-Pugh score and female gender were independently associated with mHE. mHE was associated with a poorer QOL. Follow-up assessment three years later showed that seven patients had died, while six were lost to follow-up; these patients had significantly higher baseline Child’s scores. Of the remaining patients, 36/49 (73 percent) agreed to a repeat evaluation. In this group, none had mHE. QOL remained impaired despite the resolution of mHE.
Conclusion It has been shown for the first time that mHE can revert to a normal state in a significant proportion of patients with well-compensated cirrhosis.

Keywords: cirrhosis, hepatic encephalopathy, minimal hepatic encephalopathy
Singapore Med J 2009; 50(3): 255-260

Chong E, Poh KK, Shen L, Chai P, Tan HC
Correspondence: Dr Eric Chong, ericchong80@hotmail.com

ABSTRACT
Introduction We hypothesised that diabetic patients with normal baseline renal impairment who do not receive prophylaxis before percutaneous coronary intervention (PCI) are at an increased risk of developing contrast-induced nephropathy (CIN).
Methods We conducted a cohort study involving 839 patients who underwent PCI between 2004 and 2006, and divided them into three groups: Group A (304 diabetics with normal baseline serum creatinine [Cr] of less than 1.5 mg/dL); Group B (465 non-diabetics with normal Cr); Group C (70 patients with impaired baseline renal function with Cr more than or equal to 1.5 mg/dL). CIN prophylaxis, including oral N-acetylcysteine and saline hydration, were administered only to Group C patients.
Results The median age for Groups A, B and C was 58, 56 and 64 years, respectively. The prevalence of hypertension in Groups A, B and C was 76.3, 56 and 85.7 percent, respectively. Baseline demographics were comparable among the three groups with regard to gender, left ventricular systolic function and contrast volume use. Incidences of CIN in Groups A, B and C were 8.9 percent, 4.3 percent and 4.5 percent, respectively (p-value is 0.042). The incidence of CIN in diabetic patients with a normal baseline Cr who did not receive prophylaxis (Group A) was significantly higher than in the other two groups (p-value is less than 0.001).
Conclusion Our findings suggest that diabetic patients, despite having a normal baseline Cr, are at an increased risk of developing CIN post-PCI. Routine prophylaxis in this cohort may be beneficial.

Keywords: contrast-induced nephropathy, diabetes mellitus, percutaneous coronary intervention, renal function
Singapore Med J 2009; 50(3): 250-254

Smith SI, Opere B, Goodluck HT, Akindolire OT, Folaranmi A, Odekeye OM, Omonigbehin EA
Correspondence: Dr Stella Ifeanyi Smith, stellaismith@yahoo.com

ABSTRACT
Introduction Microorganisms are transferred to everyday objects from the environment and infected individuals. Pathogenic microbes are transmissible from the air, skin, hands and other interpersonal contacts and cause diseases most of the time. This study centres on the microbial assessment of telephone receivers, their ability to transfer bacterial infections and the isolation of these microorganisms from receivers, with an emphasis on Staphylococcus aureus and its antibiotic susceptibility pattern.
Methods 1,591 isolates were obtained from roadside telephone booths in 16 different locations in the Lagos metropolis. They were all characterised using the Cowan and Steel’s manual, after which the antimicrobial susceptibility pattern of the most frequently-occurring isolate was determined.
Results Of all the locations, Oshodi was found to have the largest number of microorganisms, with Akoka having the least. The organisms were Providencia, Klebsiella, Citrobacter, Enterobacter, Proteus, Escherichia, Staphylococcus, Bacillus, Streptococcus, Micrococcus and yeast. Staphylococcus spp. was the most frequently occurring, making up 20.2 percent of the total number of isolated organisms, followed by Bacillus (18 percent), while Enterobacter and Citrobacter were the least common. 44 percent of the total Staphylococcus screened for an antimicrobial susceptibility pattern showed high resistance to most of the antibiotics used.
Conclusion This result could be related to the emergence of Staphylococcus-resistant strains, especially in a highly-populated area where there are health and hygiene problems and where drugs are abused. Precautions should be taken to prevent the spread of infectious diseases through the use of public telephones.

Keywords: antibiotic resistance, antimicrobial susceptibility pattern, Staphylococcus aureus, telephone receivers
Singapore Med J 2009; 50(2): 208-211

Awd Allah RS, Dkhil MA, Farhoud E
Correspondence: Dr Mohamed Abdel-Monem Dkhil, mohameddkhil@yahoo.com

ABSTRACT
Introduction An investigation was carried out to determine the morphological characteristics of fibroblasts in two portions of the vocal fold (VF) mucosa, the macula flava (MF) and Reinke’s space (RS), of three different age groups: newborns, adults and geriatrics.
Methods Normal human VF obtained from autopsy cases were included in this study: four from mature newborns; four from middle-aged adults; and four from geriatric cases. Fibroblasts in RS and MF were investigated by transmission electron microscopy.
Results The fibroblasts of the MF in both adults and newborns tended to be stellate in shape, with a small nucleus/cytoplasm (N/C) ratio and a well-developed rough endoplasmic reticulum (rER) and Golgi apparatus (GA). Most of the fibroblasts present in RS were oval in newborns and spindle-shaped in adults, with a large N/C ratio and less developed rER and GA. The majority of fibroblasts of the geriatric MF were stellate in shape; while in geriatric RS, the majority of fibroblasts were spindle-shaped with an N/C ratio of 0.5 to 2.0 as in the case of adults. However, the development of rER and GA was less marked in geriatrics than in adults.
Conclusion Histological changes of fibroblasts in the VF mucosa are one of the important causes of the change in voice quality with ageing. Furthermore, geriatric changes in the vocal ligament can be attributed to the activities and the presence of ageing processes in fibroblasts of geriatric VF mucosa.

Keywords: fibroblasts, human vocal fold mucosa, macula flava, Reinke’s space
Singapore Med J 2009; 50(2): 201-207

Gupta PP, Yadav R, Verma M, Gupta KB, Agarwal D
Correspondence: Dr Prem Parkash Gupta, gparkas@yahoo.co.in

ABSTRACT
Introduction In recent years, there has been increasing interest in diagnosing various components of chronic obstructive pulmonary disease (COPD) using high-resolution computed tomography (HRCT). The present study was undertaken to evaluate HRCT features in patients with COPD.
Methods 40 male patients with COPD (age 40 years or older) and with a significant smoking history (20 pack-years or more) were included in the study. They were evaluated for HRCT features including vascular attenuation and distortion, mosaic attenuation pattern, directly visible small airways, low attenuation areas of emphysema and measures of hyperinflation of the lungs: tracheal index, sterno-aortic distance, thoracic cage ratio and thoracic cross-sectional area.
Results The tracheal index ranged from 0.46 to 0.94; Saber-sheath trachea was found in 14 patients. The mean thoracic cage ratio at two levels, carina and 5 cm below carina, were 0.69 (range 0.61–0.78) and 0.73 (range 0.62–0.83), respectively. Sterno-aortic distance at carinal level ranged from 1.43 to 4.55 cm, with a mean of 3.00 cm. Directly visible small airways was the commonest finding (36 patients), followed by vascular attenuation (25 patients), mosaic attenuation pattern (16 patients) and vascular distortion (8 patients). Among various subtypes of emphysema, centriacinar emphysema was commonest (16 patients), followed by paraseptal (13) and panacinar emphysema (11).
Conclusion There are certain specific HRCT features of emphysema and it is possible on HRCT to identify the subtypes of emphysema, such as centriacinar, panacinar and paraseptal emphysema. Various features of hyperinflation can also be well identified and quantified on HRCT.

Keywords: chronic bronchitis, chronic obstructive pulmonary disease, emphysema, high-resolution computed tomography
Singapore Med J 2009; 50(2): 193-200

Noshad H, Sadreddini S, Nezami N, Salekzamani Y, Ardalan MR
Correspondence: Dr Hamid Noshad, hamidnoshad1@yahoo.com

ABSTRACT
Introduction Ever since peritoneal dialysis (PD) was introduced as a form of renal replacement therapy, its efficacy and complications have been compared with that of haemodialysis (HD). The aim of this study was to determine the efficacy and outcome of PD in comparison to HD in our region.
Methods We compared 60 patients on PD with 60 matched patients on HD in Tabriz’s Sina Hospital during the period 2004–2006. The technique, patients’ survival and quality of life were compared by means of a health-related quality-of-life questionnaire (GHQ-28).
Results There was no significant difference in the mean age and duration of dialysis between patients on PD and HD. Survival of diabetic patients was better with HD than PD, but in non-diabetic patients, there was no difference in the survival rates between the two groups. Among patients on PD, diabetics had a 25 percent higher mortality rate and non-diabetic patients had a three percent higher mortality rate than their corresponding counterparts on HD. In all four axes of the questionnaire, i.e. psychophysical dysfunction, stress and sleep disorders, social dysfunction and major depression, PD patients had lower scores than HD patients (p-values are less than 0.001, less than 0.001, equal to 0.002 and less than 0.001, respectively), indicating that patients on PD had a better quality of life compared to those on HD.
Conclusion In this study, technique, patients’ survival and their quality of life were better on PD than on HD. However, survival and mortality of diabetic patients on HD were better than those on PD.

Keywords: haemodialysis, peritoneal dialysis, quality of life
Singapore Med J 2009; 50(2): 185-192

Roudbari M, Roudbari S, Fazaeli A
Correspondence: Dr Masoud Roudbari, mroudbari@yahoo.co.uk

ABSTRACT
Introduction The practice of breastfeeding, an important need for infants, can be affected by several factors that need to be investigated. This study was designed to survey the patterns and period of breastfeeding and its associated factors in women.
Methods The study was performed in Zahedan, southeast Iran, in 2004–2005, with a sample of 450 mothers via a questionnaire to collect information about the period of breastfeeding and some important factors concerning both mothers and children.
Results The exclusive breastfeeding ratio obtained from this study was 98 percent. The proportion of breastfeeding in months 1, 3, 6, 12 and 24 after birth were 92 percent, 85 percent, 69 percent, 56 percent and 8 percent, respectively. The median breastfeeding period was 15 months, with a standard error of 1.17. The period of breastfeeding showed a significant relationship with the age of the children and mothers, the mothers’ education level, night breastfeeding, breastfeeding to an ill child, breastfeeding during a mother’s illness and the frequency of breastfeeding per 24 hours. The Cox regression also confirmed a significant relationship between the period of breastfeeding and the above-mentioned variables, except for mother’s education level and breastfeeding to an ill child.
Conclusion Young pregnant women need to be aware of the importance of breastfeeding and of avoiding the reduction or interruption of the breastfeeding period. It is recommended that the health authorities incorporate training and education programmes as well as healthcare measures to their family health programmes in order to overcome the problems of insufficient breastfeeding.

Keywords: breastfeeding patterns, breastfeeding period, health programme, pregnancy
Singapore Med J 2009; 50(2): 181-184